Multiple Myeloma: Practice Patterns of Oncology Nurses

Beth Faiman, MSN, APRN-BC, AOCN®Nurse Practitioner, Cleveland Clinic

Marilyn Haas, PhD, ANP-COncology Consultant, Institute for Medical Education and Research

The research presented was conducted and supported by IMEResearch. Presented at ONS Congress, May 14-16, 2010, San Diego, CA.

Pathophysiology of Multiple Myeloma (MM)

Multiple myeloma (MM) is a clonal B-cell tumor of slowly proliferating plasma cells in the bone marrow (BM).

Cancerous plasma cells are the result of a multistep malignant transformation in which genetic damage occurs to the pre-B cell.

Cancerous plasma cells bind to the BM stroma cell receptors which releases osteoclast-activating factors. This can lead to increased bone resorption, bone lesions, osteoporosis and hypercalcemia.

Overproduction of plasma cells in the bone marrow can lead to anemia.

Renal tubular capacity for re-absorption is exceeded by excess MM protein which leads to renal impairment.

Faiman, B. Clinical Updates and Nursing Considerations for Patients with Multiple Myeloma. Clinical Journal of Oncology Nursing, 11, 831-840.

Stewart, A. K., and Fonseca, R. (2005). Prognostic and therapeutic significance of myeloma genetics and gene expression profiling. Journal of Clinical Oncology, 23(26), 6339-6344.

Sanders, PW et al. Pathobiology of cast nephropathy from human Bence Jones proteins. J Clin Invest 1992; 89:630

Bone Marrow Plasma Cells

Lytic Bone Lesions

Prevalence and Risk FactorsPrevalence data

It is estimated that 20,580 men and women (11,680 men and 8,900 women) will be diagnosed with and 10,580 men and women will die of myeloma in 2009.

Overall survival has increased significantly from 1975–2005 Risk factors

Age (rarely occurs before age 45; 66% of cases diagnosed at ≥60 year).

Gender (slightly more prevalent in men)Race (affects twice as many African Americans as Caucasian)Exposure to ionizing radiationExposure to environmental toxins: pesticides, herbicides, dioxin,

petroleum products, Agent Orange (herbicide used in Vietnam War)

Immune system disordersMost causes unclear

American Cancer Society. Available at: http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdfRies LAG, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1975-2001. Available at: http://seer.cancer.gov/csr/1975_2001/

NCCN Recommended Agents to Treat Multiple Myeloma

Primary conventional chemotherapy—FDA approved – Melphalan/prednisone (MP)– Vincristine/doxorubicin/dexamethasone (VAD)– Dexamethasone– Thalidomide/dexamethasone (TD)– Liposomal doxorubicin/vincristine/dexamethasone (DVD)– Velcade/Thalidomide/Dexamethasone (VTD)– Velcade/Revlimid/Dexamethasone (VRD)– Velcade/Melphalan/Prednisone (VMP)- non-transplant candidate– Melphalan/Prednisone/Thalidomide (MPT) )- non-transplant candidate– Melphalan/Prednisone/Thalidomide (MPR) )- non-transplant candidate– Revlimid and low dose Dexamethasone (Rd)

Salvage therapy– Repeat primary conventional therapy (if relapse at > 6 mo)– Cyclophosphamide-VAD– High-dose cyclophosphamide– Thalidomide ± dexamethasone (consider prophylactic anticoagulation)– Bortezomib– DT-PACE (consider prophylactic anticoagulation)– Arsenic trioxide/vitamin C– High-dose steroids– Liposomal doxorubicin and bortezomib – Revlimid and standard dose Dexamethasone (RD)

Online. Available: http://www.nccn.org/professionals/physician_gls/PDF/myeloma.pdf. Accessed March 26, 2010.

Study Significance and Background

Exciting new developments in the treatment of multiple myeloma (MM) have improved both survival and quality of life. However, management of this disease can be complex.

Oncology nurses (ONs) are in a unique and powerful position to observe adverse effects, raise physician/patient awareness, and ensure proactive management of side effects related to novel agents.

Purpose

• Practice Pattern Survey (PPS) is the process of data collection from oncology nurses that, upon analyses, establishes practice trends, reveals knowledge deficits, demonstrates the degree to which evidence-based and national guidelines are incorporated, and reveals gaps in practice.

• This study assessed the PPS of oncology nurses with regard to the treatment of MM.

Materials/Methods

A 23-item survey was developed from a review of the literature and with expert oncology nurse input.

A convenient sample was obtained from IMEResearch® database.

Online and written surveys were distributed prior/during ONS 10th IOL conference.

The domains of the survey included demographics, knowledge, attitudes, and practice behaviors related to treatment of MM.

Evaluation

Ninety ONs responded to the survey. The sample was comprised of staff nurses and nurse clinicians (53%), and 82% had obtained a bachelor’s degree or higher.

Each item focused on relevant aspects of side-effect monitoring, oncology nursing management, and general knowledge related to MM and bortezomib, lenalidomide, pegylated liposomal doxorubicin, and thalidomide.

ResultsThe majority of nurses reported peripheral neuropathy

(PN) as the most frequently occurring side effect of bortezomib (51%) and thalidomide (41%) therapy.

In addition, ONs reported PN as the most challenging side effect of bortezomib and thalidomide to manage (62% and 47% respectively).

Management of PN symptoms included pharmacologic use of anticonvulsants and dose reductions of anti-myeloma therapy (70% and 73% respectively).

Strategies for assessment of PN symptoms in MM were gait/balance (85%) and touch/sensation (86%), but only 33% of nurses surveyed reported using a standardized assessment tool for PN symptoms.

Discussion

This innovative PPS was developed to reveal knowledge deficits and describe practice patterns of ONs integral to the care of patients with MM.

Of domains surveyed, PN management was regarded by ONs as a major side effect of newer therapies. Interventions may include development of a PN tool to assess symptoms and an education care plan to prevent and treat PN symptoms.

Further research is warranted to evaluate effective non-pharmacologic prevention and treatment strategies for PN.